Professional Documents
Culture Documents
in
ENT and Head & Neck Surgery
Image-Based Case Studies
in
ENT and Head & Neck Surgery
Prepageran Narayanan
MBBS (Malaya) MS ORL (UM) FRCS (Ed) FRCS (Glas)
Professor
Senior Consultant Otolaryngologist and
Head and Neck Surgeon
Department of Otorhinolaryngology
Faculty of Medicine
University of Malaya
Kuala Lumpur, Malaysia
Foreword
Ghauth Jasmon
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All rights reserved. No part of this book may be reproduced in any form or by any means
without the prior permission of the publisher.
This book has been published in good faith that the contents provided by the authors contained
herein are original, and is intended for educational purposes only. While every effort is made
to ensure accuracy of information, the publisher and the authors specifically disclaim any
damage, liability, or loss incurred, directly or indirectly, from the use or application of any
of the contents of this work. If not specifically stated, all figures and tables are courtesy of
the authors. Where appropriate, the readers should consult with a specialist or contact the
manufacturer of the drug or device.
ISBN 978-93-5090-089-5
Printed at
Dedicated to
My beloved parents:
for your everlasting inspirations and motivations.
My family: Dr Salmah Ismail, Nur Rabbaniyyah, Muhammad Iqbal,
Ahmad Farhan, and Mursyid Syaqeer.
My students, past and present.
Rahmat Omar
Ghauth Jasmon
Vice Chancellor
University of Malaya
50603 Kuala Lumpur
Preface
It is our pleasure to write a questions and answers book in ENT and Head
and Neck Surgery which seems appropriate for the purpose of exercise and
quick revision especially to our undergraduate and postgraduate students. The
fundamental will still be the core of this book with applied and functional
knowledge added for integration. These are based on real scenarios and clinical
findings which were encountered during daily outpatient practice and in the
operating table during surgery. The cases were carefully selected to represent
the main issue of particular question.
Almost all the images were taken and edited by the first author. The
book is divided into four sections; Otology, Rhinology, Head and Neck, and
Laryngology. Special techniques like endoscopy and videostroboscopy were
used to enable excellent high quality color photographs to be taken especially
from the ear, nasal cavity, and larynx.
This book is complementary to the Ear Nose Throat Colour Atlas and
Synopsis which was published earlier by University of Malaya Press. It would
be an ideal resource for exam preparation and revision; hopefully readers
would find it useful and practical. For qualified specialists and ENT surgeons,
this book would be an indispensable quick reference.
We would like to thank the patients appearing in this book, as without
their willingness and cooperation this work would not have been completed.
Special thanks to the medical officers in training and colleagues from the
Department of Otorhinolaryngology, University of Malaya, who had directly
or indirectly contributed in any way in the production of this book.
Rahmat Omar
Prepageran Narayanan
Contents
1. Otology................................................................................................. 1
(Q. 1 to 43)
2. Rhinology............................................................................................ 44
(Q. 44 to 76)
4. Laryngology....................................................................................... 105
(Q. 103 to 124)
Abbreviations
AA : atticoantral
BCC : basal cell carcinoma
BERA : brainstem evoked response audiometry
CA : carcinoma
CaHA : calcium hydroxyapatite
CAT : combined approach tympanoplasty
CO2 laser : carbon dioxide laser
CP : cerebellopontine angle
CSF : cerebrospinal fluid
CSOM (AA) : chronic suppurative otitis media (atticoantral)
CSOM (TT) : chronic suppurative otitis media (tubotympanic)
CT scan : computed tomography-scan
DCR : dacryocystorhinostomy
DNS : deviated nasal septum
ET : Eustachian tube
FBC : full blood count
FNAC : fine needle aspiration cytology
FOR : fossa of Rosenmller
GA : general anesthesia
HPE : histopathological examination
HRCT : high resolution computed tomography
IAM : internal auditory meatus
LPR : laryngopharyngeal reflux
MEE : middle ear effusion
MRI : magnetic resonance imaging
MRM : modified radical mastoidectomy
M&G : myringotomy and grommet
OMC : osteomeatal complex
PNS : postnasal space
PTA : pure tone audiogram
SNHL : sensorineural hearing loss
TB : tuberculosis
TM : tympanic membrane
TT : tubotympanic
VS : vestibular schwannoma
1 Otology
Questions
Otology
(Abbreviations: A, anterior; P, posterior)
Otology
5
B
Q. 9. A male teenager presented with a painful left ear for 2 days
duration followed by itchiness and inability to close the eye on
the same side.
a. Describe the findings as shown.
b. What is the diagnosis?
c. Outline further management of this patient.
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
7
Otology
c. What are the alternative procedures that can be carried
out and in what condition?
10
Q. 19. What is the pathology seen and what would be the next course
of action in this patient with hearing loss?
Q. 20. a. What does this picture show?
b. What would have contributed to this appearance?
Otology
11
Q. 22. This patient presented with bleeding from the left ear.
a. What are the possible diagnoses?
b. Outline the subsequent management.
12
Otology
13
B
Q. 24. a. What does this image show?
b. What are the differential diagnoses and how do you differentiate
them?
c. What are the clinical features?
d. Outline the subsequent management.
Image-Based Case Studies in ENT and Head & Neck Surgery
14
Otology
15
B
Q. 27. A 45-year-old lady complained of right-sided hearing loss, which
has become worse since her last pregnancy. Examination revealed
a normal tympanic membrane and the tuning fork tests showed
a moderately severe conductive hearing loss. She underwent
surgery and reconstructive procedure was performed.
a. What is the diagnosis?
b. Describe the findings as shown in Figures (A) and (B)?
c. What procedure would probably have been performed?
Image-Based Case Studies in ENT and Head & Neck Surgery
16
B
Q. 28. A 29-year-old lady was involved in a road traffic accident and
sustained intracranial injury. She was referred to the ENT team
few days later for the complaint of reduced hearing affecting the
left side. Otological examination revealed above findings.
a. What is the clinical sign demonstrated in Figure (A) and on
otoscopic evaluation in Figure (B)?
b. What other signs should be looked for?
c. How would this patient be managed further?
A
Otology
17
B
Q. 29. This child presented in the clinic with the above findings.
What is your diagnosis and subsequent management?
Image-Based Case Studies in ENT and Head & Neck Surgery
18
A
Otology
19
B
Q. 31. A 69-year-old lady presented with pulsatile tinnitus involving
the left ear associated with mild decrease in hearing. Otoscopic
examination and subsequent imaging study was ordered.
a. Describe the otoscopic findings.
b. What does the imaging study show?
c. Give the possible diagnoses.
d. Outline the treatment.
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
21
B
Q. 33. This child had surgery done for profound hearing loss. Related
intraoperative images were as shown.
a. What surgery was performed?
b. List its indications.
c. What are the necessary preoperative evaluations needed to
be done?
d. How would this child be monitored postoperatively?
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
a. Describe the otoendoscopic findings.
b. What are the roles of hearing test and audiometry in this instance?
c. How would you tell the patient regarding the prognosis?
23
Image-Based Case Studies in ENT and Head & Neck Surgery
24
B
Q. 36. A 14-year-old teenager presented with longstanding history of
reduced hearing affecting the left ear. Tuning forks test showed
negative Rinnes test on the left with ipsilateral lateralization on
Webers test. X-ray was ordered.
a. Descibe the radiological findings.
b. What is the most likely diagnosis?
c. List its potential complications.
d. How would this patient be managed further?
Q. 37. This intraoperative image was taken during a myringoplasty.
a. Describe the step currently being taken.
b. What is its role in myringoplasty?
c. List other materials that can be used for similar purpose.
Otology
25
Q. 38. What clinical test is being performed and its significance? Under
what circumstances it is necessary?
Image-Based Case Studies in ENT and Head & Neck Surgery
Q. 39. Describe the findings of this otoendoscopic image and give the
diagnosis. Identify the structure pointed by the arrow and its
significance.
26
Otology
b. List the sequelae of this condition.
c. Outline the treatment.
27
Image-Based Case Studies in ENT and Head & Neck Surgery
28
Q. 42. This lady had ear piercing performed by a beautician 3 days prior
to consultation. Generally she felt unwell and the pinna feeling
hot.
a. Describe the findings and give the diagnosis.
b. List the potential complications that can occur.
c. Outline the treatment.
Q. 43. What procedure is being performed? Give its indications. List the
potential complications or adverse effects.
Otology
29
Answers
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
voice test and audiometry would reveal severe conductive hearing
loss.
c. The options are hearing aid, surgery, or to leave it alone. Surgery
needs to be done at several stages including myringoplasty and
ossicular prosthesis insertion. The risk of incomplete closure, 31
secondary acquired cholesteatoma, and prosthesis-related
complications need to be considered. Care of the ear from
contaminants and treatment of intercurrent infections are important
along the way.
5. a. This is an abnormal and malformed external ear which is
called microtia (micro=small). It is a congenital lesion due to
malformation of the first and second branchial arches, which are
responsible for external ear formation. It is sometimes associated
with absent ear canal, which is called canal atresia as in this case,
or a narrow ear canal, e.g. canal stenosis. There is also an accessory
skin tag or vestigial auricle.
b. The management of this condition depends on whether the other
ear is normal. If the other ear is normal externally and hearing
wise, the patient can be advised to wait until he or she is old
enough to decide, if they want surgery for cosmetic reason. This
is because one functioning ear is enough for the patient to have
a normal hearing, speech and education. If the other ear is also
abnormal, then the child must have a bone conduction hearing aid
or even a bone anchored hearing aid fitted as soon as possible to
assist hearing. A computed tomography CT scan is performed at
the age of four to rule out any external ear cholesteatoma which
will require surgery. The middle ear and mastoid were analyzed
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
which a child will complain of pain and not obstruction. In some
patients, they have dizziness and cases of persistent coughs
secondary to wax have also been reported. This is due to the vagus
nerve (Arnolds nerve) irritation as the nerve supply the innervation
to both (tympanic membrane) and the larynx. 33
c. In a child with impacted wax, removal either by syringing or
direct vision (under microscope) can be difficult due to the lack of
cooperation as the procedure can be painful. It is better to instill
wax softener, e.g. cerumol for few days to soften and dissolve the
wax before the procedure is undertaken. Syringing should not be
performed if the TM is suspected to be perforated.
11. a. There is a yellow round object at the opening of the ear canal
most likely a foreign body. Foreign body of the ear can be divided
into organic and non-organic. Organic foreign body can lead to
infection and need to be removed quickly. Insects, if alive can be
extremely painful and need to be killed with the use of any liquid.
Non-organic foreign body can be asymptomatic and left unnoticed
for some time.
b. The management of ear foreign body is by removal. A round
object would require a probe or a curved hook to be inserted
behind it, while the flat foreign bodies can be removed with the
forceps. Syringing can be used although if not used in the right
method can cause the foreign body to be pushed further inside.
Some cases of tightly impacted foreign body may require removal
under general anesthesia. Injuries to the TM or ossicles have been
reported in overzealous or unskillful attempt at the removal of
impacted foreign bodies.
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
resulting from trauma. In some cases, it occurs secondary to severe
barotrauma when sudden changes of pressure occur while flying or
scuba diving in the presence of a nonfunctioning ET. This causes
an acute marked negative middle ear pressure with collection of
fluid or even blood in severe cases. Similar appearance can also 35
be found in cholesterol granuloma with MEE.
c. Hemotympanum is usually self-resolving and no surgical
intervention is necessary. Decongestants may be prescribed
and patient is advised to perform Valsalva maneuver if possible.
Antibiotic is not necessary. In a patient, without history of trauma,
middle ear fluid obtained upon myringotomy can be sent for
pathological examination if cholesterol granuloma is suspected
and, thereafter, the patient treated accordingly.
16. a. This picture reveals a post MRM cavity where mastoid, attic and
the external ear were operated and joined together to form a single
chamber. It is usually performed to exteriorize the cholesteatoma to
render the unsafe ear into safe ear. The middle ear cavity is usually
closed off by laying the TM over the medial aspect of middle ear space
since the scutum has been removed. This is important as an open
middle ear cavity with its respiratory mucosa (goblets cells and other
mucous secreting glands) will cause a discharging mastoid cavity. In
MRM, the facial ridge is lowered sufficiently to prevent sump effect
in the mastoid bowl.
b. Complications of this surgery include injury to the dura [with or
without cerebrospinal fluid (CSF) leak], labyrinth, facial nerve and
sigmoid sinus. There can also be a profound hearing loss that is
believed due to the drills used during the surgery.
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
and scarring, and thus suggests frequent or longstanding middle ear
infection previously. Although the TM is intact, the atrophic segment
would not be able to vibrate as good as a normal TM and the energy
transmitted to the ossicles would be reduced. Audiogram will show
the severity of hearing loss. The management would be to advise the 37
use of hearing aid if the hearing loss is significant. There is no role
of surgery in this condition.
20. a. This is an endoscopic view of the left ear, where there appears
to be a white structure beneath the TM that appears to be thicker
than an abnormal TM. The attic region appears to be retracted and
could possibly have undergone surgery.
b. Based on the appearance, there are two possibilities. The white
structure could be the cartilage that was used (or even two pieces
of cartilage) that is usually used to reconstruct the attic after an
atticotomy, or the other possibility is that of incus interposition in
an ossiculoplasty or tympanoplasty.
21. a. The endoscopic view reveals a red, fleshy mass with surrounding
mucopus in the external ear canal. This appears to be an aural
polyp. It can occur due to infection, cholesteatoma, malignant
otitis externa, or even malignancy.
b. In this patient, ear swab was taken for culture and sensitivity,
and thereafter, a thorough aural toilet and examination under
microscope was performed. It is important to probe all around
the polyp to see where the stalk or where the polyp is coming
from. If it is arising from middle ear, the probe will be able to
go all around the polyp. A trial of antibiotic can be given and
subsequently polypectomy carried out using a snare. If it is arising
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
of serous otitis media (glue ear). This is typically seen in longstanding
ET obstruction commonly from childhood itself. These patients
usually present with sensation of ear fullness and blockage, inability
to equalize the ears, and in some cases hearing loss.
39
26. Brainstem evoked response audiometry (BERA). It is an objective
audiological testing, wherein sound stimulus generates electrical
responses in the cochlea (inner ear) and in the brainstem. This
response travels along the auditory pathway, resulting in waveforms,
identifiable to the site of origin by the amplitude and latency. The
advantages of BERA include noninvasive, reliability on repetitive
testing, and not affected by sedatives or drugs. Thus, it is most useful
in newborn and neonates. In adult, it is mostly ordered for acoustic
neuroma, to differentiate cochlear and retrocochlear lesion, and in
malingering patients.
27. a. Conductive hearing loss in the presence of normal TM suggests a
middle ear pathology. These may range from tympanosclerosis,
ossicular discontinuity, adhesion, or even ossicular fusion. This
patient is very likely to have otosclerosis, a condition whereby
there is a new bone formation at or about the stapes footplate thus
impeding the transmission of sound to the oval window. The lesion
is more commonly found in females and hormonal changes during
pregnancy would have accelerated the disease process.
b. Figure A shows a complete stapes structure, i.e. the footplate,
anterior and posterior crus, and its head. Figure B shows a whitish
material encircling and anchored at the lower part of the long
Image-Based Case Studies in ENT and Head & Neck Surgery
process of incus.
c. These figures gave a clue to stapedectomy with tympanoplasty
performed. Ossicular reconstruction can be done with various
commercialized materials, e.g. titanium piston, or synthetic material
such as plastipore (likely in this case since it is white in color). This
would restore the sound transmission to the round window enabling
closure of air-bone gap.
28. a. Figure A showed mastoid and postauricular skin bruise, the typical
Battles sign while Figure B showed a bluish spherical rim in the
middle ear (an indicator of resolving hemotympanum) and purplish
bruise along and around the handle of malleus with no obvious
clue of ear canal injury. These signs are highly suggestive of skull
base fractures involving the squamous temporal bone (usually
transverse fracture if TM is intact). In contrast, the presence of
these findings in infant and young children would be suspicious
of nonaccidental injury or child abuse.
b. Cranial nerves examination in particular, the facial and auditory
nerves, to document paralysis and hearing loss, respectively.
Presence of conductive hearing loss without immediate facial
palsy, sensorineural hearing loss (SNHL), or vestibular symptoms
are in favor of longitudinal fractures rather than transverse fractures
of the temporal bone.
c. In this patient, there is no facial palsy or nystagmus noted and the
40 hearing loss is mild and conductive in nature, thus a conservative
management is chosen.
29. This is typical of a subperiosteal abscess that is seen as a complication
of acute mastoiditis. This can be an emergency condition. This
child needs admission, intravenous antibiotics, CT scan to rule
out intracranial complication (upto 30% of the children can have
asymptomatic intracranial complication) with the definitive treatment
of surgical exploration of the mastoid. The postauricular incision
should be higher in children due to the incomplete elongation of the
mastoid tip as the facial nerve can be injured in a normally placed
postauricular incision.
30. This is a PTA of a patient performed in October 2001. It reveals
a dip at 4 kHz of upto 6070 decibel (dB) with normal hearing
threshold in all other frequencies. This is typically seen in noise-
induced hearing loss. The dip at 4 kHz is believed to be due to the
fact that the promontory (corresponds to 4 kHz) is the most sensitive
part of the cochlea, therefore, vulnerable to noise insults. It initially
presents as a temporary threshold shift (in early stage) that recovers
to normal hearing threshold. Permanent damage leads to a similar
audiogram as above. This is usually due to the exposure of noise
above 90 dB, 8 hours a day, 5 days a week. If this patient is working
in a noisy environment, it is vital that he is referred to occupational
health authorities and provided with appropriate ear protection while
working.
31. a. Otoscopic examination reveals a reddish mass in the inferior part
of the left middle ear behind the intact TM. This appears to be
arising from the floor of the middle ear, extending to the umbo.
b. This MRI shows a hyperintense or hypervascular mass at the left
middle ear space. It seems to be localized in this area without any
extension into mastoid air cells.
c. The possible diagnosis includes glomus tympanicum, glomus
jugulare and possibly high jugular bulb.
d. The main treatment is excision of the lesion. She needs a preoperative
angiogram and embolization to reduce the risk of bleeding from the
lesion intraoperatively. The other option is conservative, especially if
the lesion is not growing and the patient is not fit for surgery.
32. a. This HRCT scan shows a longitudinal fracture of right temporal
bone from ear canal toward the petrous apex, traversing the middle
ear space with soft tissue density at the right mastoid cavity, most
likely blood accumulation after temporal bone fracture.
b. The diagnosis is a longitudinal fracture of right temporal bone with
hematoma.
Otology
c. The possible complications from this lesion include conductive
hearing loss, facial nerve palsy, vertigo and CSF leak.
d. The management is usually conservative and depends on the
complications of the fracture. Delayed onset of facial nerve paralysis is
treated conservatively, while immediate onset of total facial paralysis 41
may require surgery in the form of decompression, reanastomosis of
cut ends or cable graft. Hearing test is always needed during follow-up
to assess any hearing loss. Neurotological examination and assessment
is important as labyrinth concussion may occur.
33. a. This child has had right cochlear implant performed.
b. The indications of cochlear implants include severe to profound
bilateral SNHL (unaided threshold >90 dB) with little or no
benefit from 3 months to 4 months trial of hearing aid. This may
be performed for congenital hearing loss in children ideally before
the age of four or in postlingual deafness in adults or older children.
Children with congenital hearing loss detected after the age of four
may not have good results.
c. The necessary preoperative evaluations include trial of hearing aid
for 36 months, no medical contraindication to undergo surgery,
good family support, preoperative HRCT to assess the anatomy of
the inner ear, otoscopic examination to rule out any middle ear
infection and assessment by audiologist and speech therapist.
d. The child needs to be followed up with the experienced audiologist
and speech therapist for cochlear implant rehabilitation. This is
probably the most crucial part of the program.
34. a. There appears to be a red and angry looking swelling of superior
part of the left pinna.
Image-Based Case Studies in ENT and Head & Neck Surgery
Otology
Decongestant nasal drops
Analgesics and antipyretics
Myringotomy to be performed when:
The eardrum is bulging and there is severe acute pain
Incomplete resolution despite antibiotics with the eardrum 43
remains full with persistent conductive hearing loss
Persistent effusion beyond 12 weeks.
42. a. These photos show red, swollen right pinna. This is acute right
pinna perichondritis.
b. The potential complications that can occur are pinna abscess,
sepsis and cauliflower ear.
c. The treatment consists of parenteral antibiotics, analgesic and
antipyretics. If abscess develops, incision and drainage needs to
be performed.
43. The procedure that is being performed is ear syringing.
The indications of ear syringing are impacted earwax and removal
of non-organic foreign body in the ear.
The potential complications include TM perforation, dislocation of
ossicular chain, conductive hearing loss, SNHL, acute dizziness, and
facial nerve palsy.
2 rhinology
Questions
B
Q. 44. These are endoscopic images of the right nasal cavity.
a. What does it show?
b. What is the clinical implication?
c. How would this patient be managed subsequently?
Q. 45. This patient presented with painful, tender nose.
a. What is the diagnosis?
Rhinology
b. What are the possible complications?
c. Outline this patients management.
45
46
Q. 48. This patient presented with recurrent bleeding from the left nostril.
a. What is the diagnosis?
b. How would this patient be managed further?
Q. 49. This patient was seen in the clinic with nasal symptoms.
a. What are the diagnoses and its possible etiologies?
Rhinology
b. What are the clinical manifestations?
c. How would this condition be managed further?
47
48
A
Rhinology
49
B
Q. 52. This is the clinical finding in a patient who presented with fever
and acute facial pain.
a. What is the diagnosis?
b. Outline the subsequent treatment.
Image-Based Case Studies in ENT and Head & Neck Surgery
50
B
Q. 53. The above patient presented with recurrent acute sinusitis.
Endoscopic finding and computed tomography scan of the
paranasal sinuses are enclosed.
a. What is the diagnosis?
b. Outline the management of this patient.
A
Rhinology
51
B
Q. 54. This patient presented with nasal bleeding and obstruction. What
is the diagnosis and its management?
Image-Based Case Studies in ENT and Head & Neck Surgery
Q. 55. This patient presented with the loss of smell. What is the diagnosis
and its subsequent management?
52
A
Rhinology
53
B
Q. 56. The above child presented with persistent unilateral nasal
discharge. How would this child be managed further?
Image-Based Case Studies in ENT and Head & Neck Surgery
54
B
Q. 57. The above patient presented with nasal discharge. Nasal
endoscopy followed by suction was performed and the findings
were as shown respectively.
What is the likely diagnosis and subsequent management?
A
Rhinology
55
B
Q. 58. The above patient presented with ulceration of the hard palate.
Computed tomography scan is enclosed.
What is the diagnosis and subsequent management?
Image-Based Case Studies in ENT and Head & Neck Surgery
56
B
Q. 59. A Chinese gentleman presented with occasional epistaxis and
reduced hearing.
a. Describe the findings on endoscopic evaluation.
b. What is the most likely diagnosis and its further management?
A
Rhinology
57
B
Q. 60. This patient presented with clear nasal drips after an endoscopic
nasal procedure.
What is the diagnosis and subsequent management?
Image-Based Case Studies in ENT and Head & Neck Surgery
58
B
Q. 61. This is a picture of a patient, who developed right eye swelling
and reduced eyesight 1 week after he suffered an upper respiratory
tract infection.
What is the diagnosis and further management?
Q. 62. This is an endoscopic view of the nasopharynx in a child.
What is seen and how should this case proceed?
Rhinology
59
Q. 64. This patient had an operation done to relieve his left nasal
obstruction. The endoscopic view is as shown.
a. Describe the findings.
b. What procedure would probably have been done?
c. What precautions are to be considered in this surgery?
60
A
Rhinology
61
B
Q. 65. A 13-year-old male presented with progressive left nasal
obstruction and occasional epistaxis. There were no other ENT
complaints of significance.
a. What test is being performed on the patient?
b. Describe the endoscopic findings.
c. What is the most likely diagnosis and its subsequent management?
Image-Based Case Studies in ENT and Head & Neck Surgery
62
B
Q. 66. This middle-aged lady had a surgery done to relieve her right
watery eye. On follow-up 3 weeks later, her eye was re-examined
and nasal endoscopy was performed.
a. Comment on the images shown.
b. What is the subsequent management?
A
Rhinology
63
B
Q. 67. A young gentleman presented with a dull headache for few
months duration, which has become persistent at the time of
consultation. Nasal endoscopy was performed followed by
imaging study.
a. Describe the imaging study findings.
b. What are the possible diagnoses?
c. How would this patient be managed further?
Image-Based Case Studies in ENT and Head & Neck Surgery
64
B
Q. 68. A lady presented with persistent left nasal obstruction for many
years, but recently sought consultation due to on-and-off blood-
stained nasal discharge, which sometimes becomes smelly.
Endoscopic findings were performed followed by imaging study.
a. Describe the nasal findings and correlate it with the radiology
image.
b. Give the diagnosis.
c. What is the etiology?
d. How would this patient be treated further?
Q. 69. This child was noted to have a slowly enlarging discolored lesion
involving her nose. There were no other similar lesions elsewhere
and the rest of the ENT examinations were unremarkable.
a. Describe the findings.
Rhinology
b. What is the diagnosis?
c. Outline treatment modalities available for this lesion.
65
Q. 71. An adult male patient allegedly fell from his bicycle and hit the
nose against gravel. There were some epistaxis noted and the
bridge of the nose became swollen.
a. Describe the X-ray findings.
b. How would it be fixed?
c. What other lesions should not be missed?
66
Rhinology
67
B
Q. 73. A middle-aged female presented with nasal discoloration and right
side nasal blockage for a month duration. She had surgery done
previously to make her nose look better. There were no obvious
pain, fever, or other nasal symptoms and she is a nondiabetic.
a. Describe the findings of the external nose and right nasal
endoscopy.
b. What are the possibilities?
c. How would this patient be treated further?
Image-Based Case Studies in ENT and Head & Neck Surgery
Rhinology
69
Q. 75. These are the nasal endoscopic images of a patient who presented
with unilateral nasal blockage.
a. Describe the findings and give the diagnosis.
b. How would this patient be managed further?
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70
Answers
44. a. This is an endoscopic view of the right nasal cavity. The inferior
turbinate is seen inferiorly and the middle turbinate appears
double with some crustings on its surface. Thus, this could be a
bifid turbinate or the lateral structure could be a large uncinate
process.
b. The clinical implication is due to the anatomical abnormality that
may obstruct the drainage and ventilation of the middle meatus.
This will cause disruption of the mucociliary clearance of the
sinuses draining into the osteomeatal complex (OMC) and lead to
chronic rhinosinusitis. These patients can present with recurrent
acute sinusitis, facial heaviness and congestion, postnasal drip
and nasal obstruction. Nasal congestion can also lead to mouth
breathing and snoring.
c. Management of most anatomical abnormalities usually require
surgical intervention if symptomatic as they do not usually resolve
with medical therapy. In this case, surgery to clear the middle
meatus to establish normal ventilation and drainage of the sinuses
Rhinology
will resolve the problems as mentioned.
45. a. This patient is most likely having nasal skin infection. However,
underlying vestibulitis should be looked for. In this condition,
infection occurs in the nasal vestibule area (the hair-bearing skin
of the nasal cavity upto the nasal valve) usually due to minor
trauma of the underlying nasal mucosa usually from nose picking. 71
The common organisms implicated are usually Staphylococcus
aureus and Streptococcus pyogenes. The clinical features include
indurated skin, swelling, and tenderness of nasal alar or the tip
of the nose, with or without sticky nasal discharge, which can be
purulent.
b. Severe cases can lead to cellulitis of the surrounding soft tissue
which can have serious consequences as this is the dangerous zone
of the face. Infection of this area can possibly cause retrograde
thrombophlebitis via the ophthalmic vein into the pterygoid
plexus and the cavernous sinus. Underlying immunocompromised
conditions should be ruled out.
c. Management consists of antibiotics (intravenous in cases of cellulitis)
with appropriate analgesics. In chronic cases or recurrent infections,
fusidic acid ointment may be applied to the nasal vestibule.
46. a. The nasal examination reveals a deviated nasal septum (DNS)
to the left with a compensatory hypertrophy of the right inferior
turbinate. The nasal obstruction on the left is further compounded
by the fact that the DNS occurs at the nasal valve region. This area,
i.e. nasal valve is the narrowest part of the entire upper airway and
contributes to at least 50% of the airway resistance.
b. The initial management of this patient consists of a thorough history
and clinical examination with endoscopic evaluation to exclude
Image-Based Case Studies in ENT and Head & Neck Surgery
Rhinology
treatment, surgical intervention can be considered, ranging from
surface cautery and submucous diathermy to the more invasive
turbinoplasty or even turbinectomy.
52. a. Image appears to be an endoscopic view of the left nasal cavity
that reveals a mucopurulent discharge from the left middle meatus.
This is the characteristic of acute maxillary sinusitis. The presence 73
of pus discharging from the middle meatus is a good indicator as
it suggests the maxilla is draining and the ostium is patent. Acute
maxillary sinusitis, that is not draining tends to present with acute
facial pain and in severe cases can cause complications, e.g. to
the orbit. The sinus X-ray shows opacity of the left maxilla that is
consistent with sinusitis. It is important to note that a unilateral
recurrent maxillary sinusitis could be due to dental infections as
the upper molars are embedded into the floor of the maxilla.
b. The management consists of antibiotics, decongestants and
analgesics in the initial stages. Recurrent episodes would indicate
an underlying dental pathology or chronic rhinosinusitis, which
should be treated accordingly.
53. a. The endoscopic view of the right nasal cavity reveals a large
middle turbinate and the computed tomography (CT) scan confirms
the clinical impression of concha bullosa. This is defined as a
pneumatized middle turbinate or simply the presence of air cell
within the middle concha. It is probably one of the most common
anatomical anomalies seen in the nasal cavity. Concha bullosa
may remain asymptomatic and only be found incidentally on nasal
endoscopy. However, it can block the OMC, which would lead to
reduced ventilation and drainage of the sinuses; thus, predispose
to recurrent acute sinusitis or chronic rhinosinusitis.
Image-Based Case Studies in ENT and Head & Neck Surgery
Rhinology
accumulation of fluid in the middle ear space. Once the diagnosis
is confirmed histologically (to exclude lymphoma especially
in WHO type III), imaging modalities (computed tomography,
magnetic resonance imaging, positron emission tomography
scan, bone scan, ultrasound of liver) are used to determine its
local extent, presence of distant metastasis, and help in staging 75
of the disease. Treatment options include radiotherapy with or
without chemotherapy depending on the stage. Myringotomy and
grommet insertion will alleviate hearing loss while the tumor is
being treated.
60. This is a bone window view of coronal cut CT scan of the PNS. There
is a defect of the right fovea ethmoidalis with herniation of intracranial
content into the nasal cavity. A clear drip after an endoscopic sinus
surgery should always be presumed a cerebrospinal fluid (CSF)
leak. Initial management includes confirming the fluid as CSF (beta-
transferrin test) and investigation to locate the site of leak. If the defect
is large, CT scan would be able to demonstrate the exact location.
However, smaller defect may be missed. Sometimes, a fluorescein
dye is used intrathecally to identify the leak. If the leak persists
(most small leaks heal spontaneously), an endoscopic repair may be
carried out. The choice of graft material for repair ranges from septal
mucoperichondrial graft to fascia lata. In some cases, lumbar drain
is inserted by some surgeons.
61. The picture shows an orbital complication of acute sinusitis. The right
eye appears swollen with its conjunctiva suffused and edematous
which also seem to be pushed inferiorly. This is usually due to
subperiosteal cellulitis, which complicates to abscess formation as
a result of extension of pus from the ethmoid sinusitis breaching
Image-Based Case Studies in ENT and Head & Neck Surgery
the lamina papyracea. The CT scan illustrates this well on the right
side, where there is opacity of the right ethmoid with collection of
pus between the medial wall of the orbit and the eyeball itself. This
causes the orbit to be compressed and may eventually result in vision
loss; thus this is an emergency. The patient needs to be admitted and
started on intravenous antibiotics. An ophthalmology consultation
should be obtained and if there is vision reduction or the presence of
sub-perichondrial abscess in the CT scan, the pus should be drained
via open Lynch-Howarth incision or endoscopically according to the
surgeons experience.
62. The image shows a moderate size adenoid tissue along the roof and
posterior wall of nasopharynx. Adenoids are normal in children
especially between the ages of 68 years. Most of them are
asymptomatic and can be left alone. Enlarged adenoids can obstruct
the nasopharynx and ET leading to mouth breathing, snoring, apnea
and glue ear. Adenoids should only be removed if they are large
and symptomatic. Nasopharyngeal CA on the other hand, originates
usually from the lateral aspect of nasopharynx (FOR) and rarely seen
in children.
63. a. This is an image of the right middle meatus. It shows an oval-shaped
opening in front of the outline of the uncinate process. There is
no polyp or mucopus noted and the OMC area appears free from
any obstruction.
76
b. An accessory maxillary ostium. This ostium is usually located more
anteriorly and found in front of the uncinate process (it can be
multiple) as compared to the natural ostium, which is sited higher
and posterior to it; thus unusual to be seen directly on viewing
using 0 endoscope. It can be the passage for an antrochoanal
polyp as it exits from the antrum before heading posteriorly toward
the choana. Physiologically, mucociliary function and drainage of
the maxillary sinus is directed toward natural ostium. If an ostia
is noted without the uncinate being removed, then it is almost
always an accessory ostia.
64. a. Image showed absence of entire left inferior turbinate with the
exception of its posterior end. Mucous membrane covering the
inferior concha remains. Opening of the nasolacrimal duct is
clearly seen and appears patent. There is a furrow and buckling
of the septum toward the opposite site likely caused by DNS. The
middle turbinate and nasopharynx can be seen.
b. Subtotal inferior turbinate trimming or turbinectomy. It was
probably done to relieve persistent nasal obstruction caused by
compensatory inferior turbinate hypertrophy secondary to the
DNS.
c. Perioperative bleeding can be significant. This is especially
so when its posterior end is encroached upon (branches from
sphenopalatine vessels). Thus, postoperative nasal packing is
necessary. This procedure should not be performed in cold
countries to avoid crustings and possible development of
secondary atrophic rhinitis. Presently, alternative procedures
are available ranging from superficial cautery, radiofrequency,
powered instruments, or even laser. These treatment options need
to be discussed with the patient and the procedure chosen should
cause minimal morbidity with lasting effects.
65. a. This patient appears to have a totally reduced airway on the left
side as demonstrated by the cold spatula test.
b. Endoscopic nasal examination revealed a mass along the floor of
the left nasal cavity below the middle turbinate.
c. A history of recurrent epistaxis in a boy should alert the clinician to
the diagnosis of angiofibroma and above-mentioned findings would
clinically confirm angiofibroma. Management consists of confirming
the diagnosis with a CT contrast, where a blush is noted due to the
vascularity of the lesion. The tumor extents are noted as it can involve
the pterygopalatine fossa or even extend intracranially. Treatment
Rhinology
is usually by surgical excision either endoscopically or via open
traditional approach after an embolization procedure.
66. a. The images reveal evidence of a post endoscopic dacryocystorhino-
stomy (DCR), which is usually performed for patients with
epiphora. The ophthalmologists usually flush the canaliculi and
if this fails to relieve epiphora, then the option of DCR is offered 77
to the patient. A silicon tune (ODonoghue or Jones) is inserted
into both the upper and lower canaliculi and delivered into the
lacrimal sac and secured intranasally.
b. The tube is kept for an average of 3 months and then removed in
an outpatient setting. In our experience, a success rate of 94% can
be achieved this way.
67. a. The PNS CT scan shows the left sphenoid sinuses filled with soft
tissue density mass or fluid that displaces the anterior sphenoidal
wall. The bony margins are thickened and ossified indicating the
possibility of osteogenesis.
b. The possible diagnosis includes left sphenoidal mucocele, polyps,
sinusitis, fungal sinusitis or sphenoidal tumor.
c. The patient will require an endoscopic examination, especially of
the sphenoid-ethmoid complex. The management would surgically
intervene, where sphenoidotomy will be required to excise and
examine the origin of the mass. Biopsy is mandatory.
68. a. The nasal endoscopic examination reveals a crusted lesion covered
with mucopus in the left nasal cavity. The PNS CT scan reveals
left nasal cavity mass with calcification.
b. The diagnosis is left nasal cavity rhinolith.
c. The etiology is the formation of calculi in the nasal cavity, which
Image-Based Case Studies in ENT and Head & Neck Surgery
Rhinology
79
3 Head and Neck
Questions
81
Q. 80. This patient presented with high fever for 3 days duration,
associated with severe odynophagia and inability to tolerate
orally. Neck examination revealed multiple tender cervical
lymphadenopathy.
a. Describe the findings on throat examination.
b. What is the diagnosis?
c. What complications can occur?
d. How would this patient be managed?
Image-Based Case Studies in ENT and Head & Neck Surgery
82
83
84
Q. 86. This child presented with recurrent purulent discharge from the
lower neck near midline. Neck exploration was performed after
the infection settled and specimen as shown was obtained.
a. What is the diagnosis?
b. Where else in head and other areas similar lesion can occur?
Image-Based Case Studies in ENT and Head & Neck Surgery
86
Q. 88. This patient presented with a reduced hearing and mild nasal
speech. Oropharyngeal findings were as shown.
a. What is the diagnosis?
b. What is the likely cause of his reduced hearing in relation to this
finding?
c. How would this patient be managed further?
Q. 89. This is an intraoperative finding during a routine surgery for a
87
Image-Based Case Studies in ENT and Head & Neck Surgery
88
B
Q. 90. This patient presented with multiple firm swellings of various
sizes involving the skin of the whole body. He also has a bigger
neck lump on the right side of his neck.
a. What is the diagnosis?
b. What are the other manifestations of the disease in the head
and the neck area?
A
90
B
Q. 94. A 54-year-old female with noninsulin dependent diabetes mellitus
presented with severe odynophagia and fever since 4 days prior
to admission. She denied having difficulty in breathing or stridor.
On examination, she appeared dehydrated and the neck was
swollen. Random blood sugar test showed reading of 18 mmol/l.
Imaging studies were ordered as shown.
a. Describe the findings of both radiological images.
b. What is the likely diagnosis?
c. Outline further management of this patient.
Image-Based Case Studies in ENT and Head & Neck Surgery
92
B
Q. 95. This image was taken during an oncologic surgery for tongue
carcinoma. The submandibular gland was retracted downward
on the left and the opposite view at the completion of surgery.
a. What is the likely surgery performed?
b. Identify the structures as numbered.
Head and Neck
Q. 96. This gentleman presented with recurrent painful tongue lesions
which usually lasted for few days.
a. Describe the lesions.
b. What is the diagnosis?
c. How would you manage this patient optimally?
93
Q. 97. This is the image of the tongue of a female patient who presented
with complaint of blood stained to frank bleeding from the mouth.
a. Describe the lesion shown.
b. What is the most likely diagnosis?
c. Describe the methods for its removal and justify the reasons.
Image-Based Case Studies in ENT and Head & Neck Surgery
94
95
Image-Based Case Studies in ENT and Head & Neck Surgery
96
Q. 100. This lady presented with fever and swollen neck of few days
durations. Blood test showed leukocytosis and culture showed
no growth.
a. What is the diagnosis?
b. How is this condition managed?
Head and Neck
Q. 101. These instruments were designed to be used for oro-and hypo-
pharyngeal procedures.
a. Name the instruments.
b. What are its clinical uses?
97
adequately.
99. a. The image shows multiple rounded lesions arising from the inner
aspect of the mandible. The gingiva and teeth are normal. The
diagnosis is torus mandibularis which is a slow-growing benign
bony mass.
b. This lesions can be left alone as it is usually asymptomatic and
found by chance.
100. a. The most likely diagnosis is Ludwigs angina.
b. She should be admitted and started on parenteral antibiotics.
Beware of the upper airway obstruction as the submental swelling
will push the tongue backward and obstruct the upper airway.
Intubation or tracheostomy can be performed to relieve the upper
airway obstruction. Incision and drainage can be performed if
abscess is formed. A transverse incision extending from one angle
of mandible to the other is made with vertical opening of the
midline musculature of tongue by using a blunt hemostat.
101. a. These are angled biopsy forceps (the upper two instruments)
with an upturn and sideway biting angles used typically for
hypopharyngeal area. The lower black-colored instrument is
Kaluskar forceps which is widely used for the removal of foreign
body at tongue base area.
b. These instruments are used clinically for removal of foreign body
and taking biopsy.
102. a. The surgery being performed is excisional lymph node biopsy.
104 b. It is indicated to confirm the diagnosis by histopathological
examination usually necessary in suspected lymphoma.
c. The alternative technique is FNAC as this can be performed
as office clinic procedure with 8090% sensitivity (operator
dependent).
4 Laryngology
Questions
B
Q. 103. An immigrant lady presented with the history of hoarseness
preceded by chronic cough. Laryngeal examination was performed
and a chest X-ray ordered. Mantoux test was negative.
a. Describe the laryngeal lesion as shown.
b. Describe the chest X-ray findings.
c. What is the most likely diagnosis?
d. How would this patient be managed further?
Image-Based Case Studies in ENT and Head & Neck Surgery
106
B
Q. 104. A young Malay lady presented with sudden onset of hoarseness
and stridor after ingesting tablet containing evening primrose oil.
Laryngeal endoscopic view and lateral soft tissue X-ray attached.
a. Describe the X-ray findings.
b. Explain the endoscopic findings.
c. What is the likely diagnosis?
d. How would this patient be managed further?
Q. 105. This is an intraoperative view of a patient, who is undergoing a
total thyroidectomy.
Laryngology
a. Describe what is being highlighted.
b. What would happen if this is severed or damaged and how
to avoid this injury?
107
Q. 106. This is the neck image of a patient, who had his larynx removed
for the recurrence carcinoma of larynx.
a. Describe the findings.
b. What is needed to be considered for this patient?
Image-Based Case Studies in ENT and Head & Neck Surgery
108
B
Q. 107. This patient presented with a chronic breathy voice after thyroid
surgery performed many years earlier. Videostroboscopy was
performed and still images taken during phonation are enclosed.
a. Describe the findings and likely diagnosis.
b. How would this patient be managed further?
Q. 108. A 9-year-old school boy presented with history of hoarse voice
for 3 years duration.
Examination under anesthesia was performed and findings were
Laryngology
as shown.
a. Describe the findings.
b. What is the likely diagnosis?
c. What is the subsequent treatment?
109
Q. 109. This patient presented with the hoarseness of voice for few months
duration. He gave the history of chronic smoking earlier, but no
alcohol consumption noted. Direct laryngoscopy was performed
and intraoperative image was as shown.
a. Describe the findings.
b. What is the likely diagnosis?
c. How would this patient be managed further?
Image-Based Case Studies in ENT and Head & Neck Surgery
110
B
Q. 110. A 1-year-old child presented with worsening stridor and difficulty
in breathing for which emergency tracheostomy was performed.
Computed tomography scan was ordered and subsequently the
child scheduled for direct laryngoscopy. He was born prematurely
at 34 weeks and managed in pediatric intensive care unit, after
which he was discharged well.
a. Describe the findings on direct laryngoscopy and the
Computed tomography scan findings.
b. What is the diagnosis?
c. How would this child be managed further?
A
Laryngology
111
B
Q. 111. This young patient presented to outpatient ENT clinic with a
feeling of food sticking in the throat and fluctuating voice change
usually worse in the morning. There were no nasal symptoms
or recent respiratory tract infection. Videostroboscopy was
performed and still images on adduction and abduction were
shown, respectively.
a. Describe the findings.
b. What is the most likely diagnosis?
c. How would this case proceed?
Image-Based Case Studies in ENT and Head & Neck Surgery
112
Laryngology
a. Describe the findings.
b. What is the diagnosis?
c. Is there any role of speech therapy in this case?
d. How would this lesion be treated?
113
114
C
Q. 116. These images showed surgery being performed for voice
improvement in adductor vocal fold palsy.
a. What thyroplasty technique is being shown?
b. List the advantage of this surgery as compared to others.
c. What potential complications can occur?
d. Name the injection instrument being used.
Q. 117. A child was intubated due to upper airway obstruction for 10
Laryngology
days duration. Intraoperative laryngeal assessment was performed
prior to definitive surgical intervention.
a. Describe the findings.
b. What is the diagnosis?
c. List the sequelae if this lesion is not being managed optimally.
115
Image-Based Case Studies in ENT and Head & Neck Surgery
116
B
Q. 118. This is an intraoperative image of a 3-week-old infant, who
presented with stridor. Figures shown were the pre- and
postoperative views, respectively.
a. Describe the findings.
b. Give the diagnosis.
c. What surgery likely was performed?
A
Laryngology
117
B
Q. 119. a. Describe the findings of these images.
b. Give the diagnosis.
c. How would this patient be managed further?
Image-Based Case Studies in ENT and Head & Neck Surgery
118
Laryngology
119
B
Q. 121. A 30-year-singer suddenly noted sudden change of voice and
laryngeal irritation while singing. She stopped immediately and
gave rest to her voice. However, her voice did not improve; she
decided to get medical advice a day later.
a. Describe the laryngeal findings and give the diagnosis.
b. How is this condition treated?
Image-Based Case Studies in ENT and Head & Neck Surgery
Q. 122. Compare these two endotracheal tubes and list its differences.
What are the indications for its usage?
120
A
Laryngology
121
122
Laryngology
patient is highly infectious in an apparently non-reacting Mantoux
called anergy state. Cough etiquette and wearing of suitable face
mask must be followed until sputum culture becomes negative on
treatment. Treatment entails combination of TB drug therapy for a
period of at least 6 months. Contact tracings need to be done by
local health authority and treated accordingly.
104. a. There is a thumb-shaped soft tissue swelling in the area of 123
supraglottic larynx originating from the arytenoid area. The
epiglottis is also swollen as suggested by the thickened opaque
shadow just behind the base of tongue. The air bronchogram does
not show any evidence of subglottic or tracheal narrowing.
b. The endoscopy view showed a markedly swollen epiglottis
and edematous arytenoid mucosa with no obvious erythema or
exudates seen. Pooling of saliva is not seen here.
c. Stridor in this patient occurred at supraglottic level. There
is no fever, significant pain, or purulent exudates to suggest
infection. In view of unfamiliar food eaten before and subsequent
development of symptoms, this would be very likely due to
localized hypersensitivity reaction, e.g. angioneurotic edema.
Supraglottic larynx has a rich lymphatic supply and vulnerable
to angioneurotic edema with fast onset of airway obstruction. If
the lesion occurs repeatedly, possibility of C1 esterase deficiency
needs to be considered.
d. Intravenous steroid, e.g. dexamethasone or methylprednisolone,
and antihistamine would be the first-line of treatment. Endotracheal
intubation is justified, in view of worsening airway caliber, while
waiting for the reactions to subside. Antibiotic is not necessary.
105. a. The thyroid lobe is being retracted to the opposite side. The forceps
point to the left recurrent laryngeal nerve as it ascends through
Image-Based Case Studies in ENT and Head & Neck Surgery
Laryngology
1 09. a. Image showed an irregular white lesion along the free edge of
left vocal cord extending from the vocal process of arytenoid
posteriorly and encroaching toward the anterior commissure.
b. This is very likely to be a leukoplakia. Social history of chronic
smoking would raise high suspicion of dysplasia or even malignancy.
c. The examination should proceed further to telescopic assessment 125
of the anterior commissure and subglottic area usually using a
30 or 70 endoscope. Adequate tissue biopsy needs to be taken
for histopathological examination. If the report comes back as
dysplasia, repeated biopsy needs to be done at another setting
determined at follow-up sessions. Subepithelial cordectomy can be
performed if there is no evidence of malignancy found. However, if
the basement membrane invasion is proved, then the patient needs
to be treated as having an invasive carcinoma. In case of clear-
cut malignancy, a definitive treatment should be started (usually
radiotherapy, this is a T1 lesion with a very favorable prognosis).
Alternatively, laser surgery can be performed with equally good
result by a formally trained and experienced surgeon.
1 10. a. Direct laryngoscopy reveals normal vocal cords with narrowing
of the subglottic region. The patency of the airway is markedly
reduced, which explains the presentation of stridor. The sagittal
computed tomography (CT) scan slice shows a tracheostomy in
situ with a shelf-like stenosis below the vocal cords and above the
tracheal stoma.
b. This is a typical finding in subglottic stenosis, which can be
acquired (complication of prolonged intubation).
c. Management consists of securing the compromised airway as the
Image-Based Case Studies in ENT and Head & Neck Surgery
very first step. Thereafter, imaging studies are performed (CT scan or
magnetic resonance imaging) to delineate the location and thickness
of the stenotic component. A thin fibrous stenosis can be excised
with laser, while a much thicker one may require a more aggressive
surgical treatment ranging from excision to cricoid expansion with
costal cartilage or even cricotracheal resection with reanastomosis.
In this child, the recommended initial treatment is likely Carbon
dioxide (CO2) laser excision followed by dilatation procedures.
Topical mitomycin C application can be considered. Open surgery
is advised, when this method fails.
1
11. a. The vocal cord appears to be of normal appearance and mobility;
however, the arytenoids appear to be swollen and edematous. This
typically presents as a sensation of foreign body upon swallowing
or throat discomfort.
b. This is most likely to be due to laryngopharyngeal reflux (LPR) disease.
c. After a thorough examination of the nose and nasopharynx to rule
out chronic rhinosinusitis and postnasal drip, a course of proton
pump inhibitors can be prescribed. As inflammation caused by acid
reflux heals slowly, a longer course is usually given ranging from
3 weeks to 3 months. Ideally, esophageal pH monitoring should
be performed in all cases. However, many laryngologists decided
to treat LPR based on symptoms (reflux symptom index) and the
typical endoscopic findings. Helicobaiter pylori and malignancy
should not be missed.
126 1 12. This image shows a normal left vocal cord, while the right cord
shows a swelling in its mid-membranous portion with an abnormal
vessel traversing it and areas of punctate hemorrhage. The abnormal
vessel is believed to be involved in the pathogenesis of benign vocal
fold lesions including vocal fold cyst and polyp. The normal vocal
fold vessels are much finer and run parallel to the long axis of the
vocal fold instead of transversely and tortuously, as seen in this
image. Bleeding may occur spontaneously or upon voice overuse
and it appears as punctate or subepithelial hemorrhage. Repeated
events predispose to prolonged reparative changes within the lamina
propria layer of the affected vocal cord. Initially, videostroboscopy
shows disturbance of mucosal waves, whilst longstanding untreated
lesions may manifest itself as polyp, cyst or even Reinkes edema.
In addition to the removal of the cyst, this abnormal vessel needs to
be ablated usually using a bipolar diathermy at low power setting
or alternatively by using laser [usually potassium-titanyl-phosphate
laser, or CO2 laser at defocus mode]. Pulsed dye laser is an excellent
alternative for this purpose if available.
113. a. Figure shows symmetric and bilateral nodular whitish swelling
affecting the free edge of the true vocal folds at its mid-membranous
segment.
b. This appearance is typical of mature vocal fold nodules.
c. Management has to take into account the childs behavior, parents
expectation, peer influence, and the rate of voice recovery to
normal. Speech therapy should be the primary treatment in
managing pediatric vocal fold nodules and other benign vocal fold
lesions. Adequate time and encouragement should be given with
the frequency and intensity of voice rehabilitation determined by
the speech therapist as the treatment progresses.
d. Surgical excision is needed as the callus appeared well-formed and
thickened. Intraoperative palpation gives further information on
its consistency. Microsurgical technique is preferred to minimize
disturbance of uninvolved areas of the vocal folds.
114. a. There is a yellowish rounded swelling involving the membranous
left vocal fold with the fold edge appearing evenly bulging
medially. The right vocal fold appeared edematous and its surface
whitish in color. The capillary appeared dilated and running
parallel along the right vocal fold.
b. Left vocal fold cyst with contralateral reactive vocal fold lesion
(likely to be early Reinkes edema with superficial keratoses).
Laryngology
c. Speech therapy is unlikely to resolve the problem, but it should be
targeted at postoperative period for optimal healing environment
while preventing unsupervised vocal use. She should not be
teaching too soon also. Generally, the prognosis of superficial
cyst is favorable and unlikely to recur if completely removed
(enucleated).
d. Microsurgical excision need to be performed followed by 127
postoperative voice therapy.
115. a. Figure shows the laryngeal inlet view of larynx with visible
endotracheal tube. The false vocal folds appeared normal.
However, the true vocal folds were obviously swollen and
glistening with yellowish tinge seen peripherally.
b. This is typical of Reinkes edema or polypoid corditis. In this
condition, there is an accumulation of gelatinous substance like
a gel in the subepithelial layer or Reinkes space. It commonly
occurs in chronic heavy smokers and worsens the voice quality
tremendously.
c. Endolaryngeal microsurgery by using cold instruments is generally
advocated. A more laterally placed linear incision (cordotomy) can
be done by using sickle knife or CO2 laser. Gelatinous material
is then sucked adequately and the epithelium redraped with the
excess trimmed. Tissue glue can be applied at the end, but usually
it is not necessary.
d. Adequate speech voice rest and speech therapy sessions need to
be followed. The patient must quit smoking indefinitely.
1
16. a. Figure shows injection thyroplasty technique by using autologous
fat obtained from the abdominal wall.
b. i. No body rejection
ii. Abundant material and technically not difficult to harvest
Image-Based Case Studies in ENT and Head & Neck Surgery
Laryngology
122. These are two types of endotracheal tubes used for the purpose of
microlaryngeal surgery. The metallic tube is malleable (flexometallic)
and has two cuffs at its distal end which are filled with colored saline.
The other is normal endotracheal tube with single distal cuff and was
wrapped proximally with shiny reflective tape to conceal the actual
tube.
These are the suitable tubes and their modifications intended to be 129
used for laser microlaryngeal surgery. They prevent the laser beam
striking and puncturing into the endotracheal lumen which can cause
explosion and airway fire. The double cuff offer additional protection
as the more distal cuff can still seal the endotracheal wall if the more
proximal cuff burst.
123. a. These are the endoscopic laryngeal images showing a bluish
swelling with nodular surface alike to mulberry fruit involving
the right supraglottic larynx and encroaching the medial aspect
of ipsilateral pyriform fossa. The appearance suggests a vascular
tumor most likely hemangioma. Depending on patients symptoms
and rate of growth, the possibility of malignant transformations
need to be considered. General examination should rule out similar
lesions elsewhere.
b. Magnetic resonance imaging with contrast would delineate the
extent and vascularity of the tumor especially in an attempt to
identify the blood vessels feeders amenable for embolization if
this is decided to be done.
c. In experienced hand, this can be excised surgically via transoral
approach. Good homeostatic device must be available, e.g. suction
diathermy or insulated bipolar diathermy and the used of suitable
laser, e.g. Nd:Yag or pulsed dye laser. An alternative is via lateral
pharyngotomy approach.
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